Director, Risk Adjustment Prospective Programs

Inland Empire Health Plan•Rancho Cucamonga, CA

13d•$154,128 - $204,214•Hybrid

About The Position

The Director of Risk Adjustment Prospective Programs is a strategic leader responsible for implementing, operationalizing, and optimizing the health plan's point-of-care, concurrent, and forward-looking risk adjustment initiatives. This role focuses entirely on prospective interventions, capturing accurate member health acuity before or during a provider encounter. This position executes the enterprise strategy and converts it into scalable workflows, controls, KPIs, EHR integrations, and provider-facing tools that reduce friction for independent clinicians and delegated IPAs. The primary mandate of this position is to ensure the plan's risk adjustment program is a proactive, clinically driven model. Operating within a network structure comprised of independent, Fee-for-Service (FFS) practices and delegated Independent Physician Associations (IPAs), this Director leads programs such as in-home and virtual assessments, pre-visit suspecting, point-of-care documentation supports, and concurrent validation. This leader ensures chronic conditions are documented accurately to CMS compliance standards in real time, driving revenue accuracy and improving proactive clinical care management. The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Requirements

A minimum of eight (8) years of progressive experience in healthcare managed care or risk adjustment operations, with a distinct, heavy emphasis on executing prospective (point-of-care, in-home, or concurrent) programs.
At least five (5) years of leadership and management experience leading teams, projects, initiatives, and/or cross-functional groups.
Demonstrated success improving compliant documentation capture, provider adoption, and submission integrity through EHR integrations and analytics driven suspecting
Bachelor’s degree in nursing, public health, healthcare administration or a related field from an accredited institution required
Certified Risk Adjustment Coder (CRC) or Certified Professional Coder (CPC) from AAPC or AHIMA required
Possession of an active, unrestricted, and unencommenbered Registered Nurse (RN) or Nurse Practitioner (NP) license issued by the California BRN preferred
Must have a valid California Driver’s license
Comprehensive knowledge and in-depth understanding of: Launching healthcare operations or behavioral change campaigns within a non-employed, independent FFS provider network
Prospective risk adjustment platforms, EHR alert integrations (Epic, Athena, eClinicalWorks, etc.)
Managing large-scale national prospective/IHA vendors (e.g., Signify, Matrix, Optum)
Program management, change management, and stakeholder facilitation for provider audiences.
Vendor management (SLAs, ROI, data security) and budget stewardship
Prospective risk adjustment concepts and operations; documentation standards (ICD 10 CM/HCC, MEAT), HIPAA/privacy; RADV readiness principles
Encounter/EDPS submission mechanics and downstream data quality controls
Exceptional communicator capable of convincing fiercely independent, time crunched FFS providers to adopt prospective tools into their daily workflows
Data literacy (Excel/BI tools) to monitor KPIs and communicate insights clearly
Ability to balance prospective/concurrent capture with compliance and audit readiness
Intermediate–advanced skills in using analytics tools (e.g., Excel, BI tools)
Strong presentation and facilitation skills for varied clinical audiences
Advanced ability to: Build immediate peer-to-peer credibility with network physicians
Model change leadership, clear communication, and cross‑functional collaboration
Maintain strong professional relationships with providers, internal stakeholders, and external partners
Act as a credible advocate for prospective documentation excellence, while ensuring alignment with company policies and strategies
Prioritize resources using network tiering
Drive measurable outcomes while maintaining strong provider relationships

Nice To Haves

Master’s degree in nursing, public health, healthcare administration or a related field from an accredited institution preferred
CDI certification (e.g., ACDIS CCDS) or comparable documentation improvement credential preferred

Responsibilities

Lead the implementation, optimization, and scalability of the health plan's prospective assessment programs, ensuring that historical chronic conditions and suspected HCC gaps are delivered cleanly to providers at the time of a member's visit
Oversee the strategy, vendor selection, and performance metrics for the plan’s in-home health assessment (IHA) and virtual assessment campaigns for hard-to-reach or disengaged members. Ensure documentation meets compliance standards and integrated with care management
Minimize administrative friction for independent clinicians by building EHR smart-phrases, discrete macros, and pre-visit planning summaries that easily integrate into standard primary care workflows
Partner with Contracting and Provider Relations to design and manage prospective "Per-Assessment" incentive programs or quality bonus structures that compensate independent FFS doctors for taking the extra time to complete rigorous documentation
Oversee the development of tailored prospective education modules for independent clinics on compliance documentation standards (e.g., CMS M.E.A.T (Monitor, Evaluate, Assess, Treat) criteria) at the point of patient encounter
Collaborate with delegated IPA Medical Directors to integrate the plan's prospective suspecting data directly into the IPA’s internal care gap and scheduling registries
Partner with Healthcare Data Analytics teams to optimize "suspecting engines" that evaluate historic claims, prescription data, lab results, and social determinants of health (SDOH) to predict undocumented or under-documented chronic illnesses. Set operational acceptance criteria and feedback loops
Segment the FFS provider network based on prospective actionability, focusing high-touch point-of-care tools on clinics with high volumes of "suspected but uncaptured" member HCCs
Closely align prospective risk adjustment worksheets and alerts with the Quality/HEDIS team's care gap alerts. Ensure providers receive a unified, comprehensive list of both quality and coding gaps during a patient encounter to eliminate provider abrasion
Establish data loops that automatically route newly captured or confirmed complex diagnoses from prospective programs directly into the plan's Case Management and Disease Management pipelines
Oversee internal validation audits of prospective assessments to guarantee that all codes submitted via these programs are backed by rigorous, compliant clinical documentation, mitigating RADV audit exposure
Coordinate with Claims/IT/Data Analytics teams on end-to-end submission integrity (encounter/EDPS) to prevent code drop-outs; monitor transaction errors and systemic issues
Maintain operational dashboards for throughput, accuracy, timelines, and ROI of prospective programs; drive root-cause analysis and remediation
Support selection, contracting, and ongoing performance management of vendors (in home assessments, point of care tools, NLP/AI aids); track SLAs, data security obligations, and ROI.
Manage budgets and resource allocations
Lead and develop a high-performance, engaged, and accountable team culture. Provide strategic talent guidance, oversee performance and workforce planning, and ensure clear communication and effective change leadership across the business unit. Hire, train, and manage staff, while monitoring and evaluating outcomes. Conduct performance reviews of each Team Member within IEHP guidelines
Maintain governance items (SOPs, controls, audit trails). Produce routine results reporting to senior leadership and committees
Identify process improvements and technology enhancements to increase provider adoption and documentation accuracy
Perform any other duties as required to ensure Health Plan operations and department business needs are successful